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Sleepwalking Disorder
DSM-III Diagnostic Criteria A'''. There are repeated episodes of arising from bed during sleep and walking about for several minutes to a half hour, usually occurring between 30 and 200 minutes after onset of sleep (the interval of sleep that typically contains EEG delta activity, sleep stages 3 and 4). '''B. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to influence the sleepwalking or to communicate with him or her; and can be wakened only with great difficulty. C'''. Upon awakening (either from the sleeping episode or the next morning), the individual has amnesia for the route traversed and for what happened during the episode. '''D. Within several minutes of awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation). E'''. There is no evidence that the episode occurred during REM sleep or that there is abnormal electrical brain activity during sleep. '''Differential Diagnosis Psychomotor epileptic seizures Psychomotor epileptic seizures may occur at night and produce episodes of perseverative behaviors similar to sleepwalking except that the individuals almost never return to their own beds. Also, during epileptic attacks there is total unreactivity to environmental stimuli, and perseverative motor movements such as swallowing and rubbing the hands are more common. Individuals with seizure disorders generally manifest such behaviors in the waking state as well, and the activity is associated with recordable seizure discharge. However, seizure disorders do not preclude coexisting Sleepwalking Disorder. Psychogenic Fugues Psychogenic Fugues are distinguishable from Sleepwalking Disorder on several counts: Psychogenic Fugues are rare in children, typically begin in wakefulness, have a duration of hours or days, are not characterized by disturbances of consciousness, and are usually associated with other evidence of severe psychopathology. Sleep drunkenness Sleep drunkenness (prolonged transition to a clear consciousness after awakening) may resemble Sleepwalking Disorder except for the former's appearance in the morning and high frequency of aggressive behavior. DSM-IV Diagnostic Criteria A'''. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. '''B. While sleepwalking, the person has a blank, staring face, is relatively unresponsive to the efforts of others to communicate with him or her, and can be awakened only with great difficulty. C'''. On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the episode. '''D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation). E'''. The sleepwalking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Differential Diagnosis Nonclinically significant sleepwalking episodes Many children have isolated or infrequent episodes of sleepwalking, either with or without precipitating events. The exact boundary between nonclinically significant sleepwalking episodes and Sleepwalking Disorder is indistinct. Frequent episodes, injuries, more active or violent behavior, and social impairment resulting from sleepwalking are likely to lead the child's parents to seek help and warrant a diagnosis of Sleepwalking Disorder. Episodes that have persisted from childhood to late adolescence, or that occur de novo in adults, are more likely to warrant a diagnosis of Sleepwalking Disorder. Sleep Terror Disorder It can be difficult clinically to distinguish Sleepwalking Disorder from Sleep Terror Disorder when there is an attempt to "escape" from the terrifying stimulus. In both cases, the individual shows movement, difficulty awakening, and amnesia for the event. An initial scream, signs of intense fear and panic, and autonomic arousal are more characteristic of Sleep Terror Disorder. Sleepwalking Disorder and Sleep Terror Disorder may occur in the same individual, and in such cases both should be diagnosed. Breathing-Related Sleep Disorder Breathing-Related Sleep Disorder, especially the obstructive sleep apnea syndrome, can also produce confusional arousals with subsequent amnesia. However, Breathing-Related Sleep Disorder is also characterized by characteristic symptoms of snoring, breathing pauses, and daytime sleepiness. In some individuals, Breathing-Related Sleep Disorder may precipitate episodes of sleepwalking. Parasomnia Not Otherwise Specified "REM sleep behavior disorder" is another Parasomnia (see Parasomnia Not Otherwise Specified) that may be difficult to distinguish from Sleepwalking Disorder. REM sleep behavior disorder is characterized by episodes of prominent, complex movements, often involving personal injury. In contrast to Sleepwalking Disorder, REM sleep behavior disorder occurs during rapid eye movement (REM) sleep, often in the later part of the night. Individuals awaken easily and report dream content that matches their behaviors. A variety of other behaviors can occur with partial arousals from sleep. Confusional arousals resemble sleepwalking episodes in all respects except the actual movement out of the bed. "Sleep drunkenness" is a state in which the individual shows a prolonged transition from sleep to wakefulness in the morning. It may be difficult to arouse the individual, who may violently resist efforts to awaken him or her. Again, ambulation or other more complex behaviors distinguish Sleepwalking Disorder. However, both confusional arousals and sleep drunkenness may occur in individuals with Sleepwalking Disorder. Sleep-related epilepsy and Sleep Disorder Due to Epilepsy Sleep-related epilepsy can produce episodes of unusual behavior that occur only during sleep. The individual is unresponsive and is amnestic for the episode. Typically, sleep-related epilepsy produces more stereotypicaly, perseverative, low-complexity movements than those in sleepwalking. In most cases, individuals with sleep-related epilepsy also have similar episodes during wakefulness. The EEG shows features of epilepsy, including paroxysmal activity during the episodes and interictal features at other times. However, the presence of sleep-related seizures does not preclude the presence of sleepwalking episodes. Sleep-related epilepsy should be diagnosed as Sleep Disorder Due to Epilepsy, Parasomnia Type. Substance-Induced Sleep Disorder Sleepwalking can be induced by substances or medications (e.g., antipsychotics, tricyclic antidepressants, chloral hydrate). In such cases, Substance-Induced Sleep Disorder, Parasomnia Type, should be diagnosed. Dissociative Fugue Dissociative Fugue bears superficial similarities to Sleepwalking Disorder. Fugue is rare in children, typically begins when the individual is awake, lasts hours or days, and is not characterized by disturbances of consciousness. Malingering Although individuals can feign sleepwalking as part of Malingering, it is difficult to counterfeit the appearance or behavior of sleepwalking under direct observation. DSM-5 See Non-Rapid Eye Movement Sleep Arousal Disorders